The present disclosure relates to apparatus/assembly and related methods of training and exercise such as for rehabilitation and other medical, sports, fitness settings where upper extremity support is provided by a mechanism other than gripping both rails of devices such as parallel bars and treadmills, and enablement or enhancement of upper extremity (UE) support and/or movement while using these devices is desired. Of course, selected aspects may find use in related applications.
Patient mobility aids are known for assisting with ambulatory support. The amount of support offered varies among the various assistive devices. Walkers are commonly used patient aid devices which provide ambulatory support for physically challenged individuals. Walkers typically are 3-sided, having four legs, two legs on each side. The front legs are connected with a frame structure, and the front and rear legs are also connected on each side, respectively, with frame structures, creating side frames. Upper surfaces of the lateral frames are typically provided with a surface which can be gripped by a patient, and the height of walkers can be adjusted for optimal grip support height. Standard or swivel wheels can be alternately attached to the front legs of the walker in place of the non-slip or rubber tipped post legs to create a front-wheeled walker. A walker with four rubber-tipped legs is a pick up walker. A rollator is another patient aid device which is a four-wheeled device with caster wheels in the front, standard wheels in the rear, a braking mechanism, and typically a seat. Other mobility aids include crutches, canes, Lofstrand (forearm) crutches, hemi-walkers, among others.
When one cannot support oneself or manage the device by gripping a walker or rollator and using the upper limb for support for any of several reasons, including but not limited to decreased grip, pain, weakness, weight-bearing or other orthopedic restrictions, other injury, movement precautions, or if additional postural support is desired, one of various makes/models of platform attachments can be secured to one or both lateral frames of the patient aid device, offering a way to balance and support the body to the degree desired as well as to protect an upper limb if this is needed. Platform support also provides for a way to achieve increased weight-bearing symmetry, throughout a weakened side of the body during ambulation, such as occurs with stroke. Platform use is also desirable in cases in which greater support is needed on the side opposite a dysfunctional lower limb during gait training, to support the lower limb, as the contralateral upper limb mechanically provides the support. At times, immobilization/protection of the UE is needed and the platform accomplishes this. The platform assembly also offers a way to manipulate or manage the walker/rollator when the user is unable to manage the walker by gripping the grip(s). Platforms are sometimes used unilaterally or bilaterally when excessive upper body, lower body, and/or generalized weakness exists and the arms cannot safely support the body by transmitting weight through the hand(s). Walker platforms may be needed simply when distal UE dysfunction exists, such as with poor gripping function. In these cases, unfortunately, the entire UE is necessarily immobilized on the platform. Alternate upper extremity support surfaces beyond forearm platforms, for use with walkers and other mobility aids, largely do not exist. Known platform attachments are presently only available for use with walkers or rollators with attachment mechanisms particularly designed for these patient aid devices.
For individuals who need the support of a patient aid device such as a platformed walker such as those who have suffered a stroke, yet cannot mobilize with this device due to an inability to adequately manage a platformed walker, such individuals can sometimes alternately use a hemi-walker. A hemi-walker is a large based, four-legged device held by the strong hand. The weak upper extremity hangs or rests, devoid of support or stimulation during walking, which negatively affects gait training efforts in several regards. Indeed, rehabilitative efforts to the upper extremities during functional training such as gait training is often lacking as evidenced by techniques incorporated with currently available assistive devices/mobility aids, and/or mechanical limitations imposed by these devices. Mobility aids are lacking which facilitate endeavors to normalize gait. Device(s) which would enable a sound upper limb to mobilize a weak upper limb during the functional activity of ambulation also are unavailable and significantly needed.
The user's hands remain stationary on handgrips, and/or forearms remain stationary on platform supports, when mobilizing with a walker. If the walker is advanced forward, both upper extremities advance in phase and simultaneously, often too far ahead of the rest of the body, resulting in a flexed or forward bent posture, regardless of gait pattern used. “Reciprocating” walkers exist, yet good bilateral (UE) function is required to use this kind of walker (as opposed to a standard rigid framed walker) as each side must sequentially be advanced forward (to the extent that the device's design allows), and significant risk for postural faults remains. In terms of wheel selection, swivel wheels are often needed in order for individuals to be able to turn with a platformed walker; however, those who need this functionality the most, are at greatest risk with walking with such a device due to its inherent instability. Hence, functionality of platformed patient aid devices is often somewhat lacking in effectiveness in current commercially available products, particularly in terms of use with individuals afflicted with neurologic disease. There are also expensive wheeled devices with integrated upper body support, for overground walking, some of which are equipped with a posterior seating mechanism to further safeguard against falls. The upper body is platform-supported and generally immobile when these devices are used. Consequently, a need exists for enablement of arm movement with a walker regardless of whether one arm is weak.
The positioning and stabilization of the arms when a rigid framed walker is used is in contrast to a normal human gait during which, in all but slow velocities, the arms move out of phase, each advancing with the contralateral lower extremity, creating a reciprocating gait pattern. Physiologically, physically, and neurologically, it is well known that arm movement during walking is advantageous. Neural coupling is the term which denotes the favorable neurologic effect that arm movement has on the neurologic function of the lower extremities, especially important to those recovering from injury to the nervous system for example. Patient aid devices are needed which address the need for mechanisms to enable and facilitate physiologically normal upper body movement during gait.
In the field of physical rehabilitation, parallel bars refer to an ambulatory assistive device which offers significant stable support and is often the site of initial gait training, typically followed by progression to use of another less-restrictive assistive device. Prosthetists, orthotists, occupational therapists and other professionals also use parallel bars for ambulation and other lower extremity weight bearing activities. Parallel bar units include two parallel rails, typically 10 to 15 feet in length, which are often height and width adjustable, manually or electrically. It is recognized that other lengths may be contemplated. Indeed, very short parallel bar units are available and would be ideally suited for edge of bed and household use. Each rail is secured to two or more longitudinally spaced vertical posts with one of a variety of known connection devices/methods, and thence to the floor or walking platform. The patient uses of one's arms for supportive purposes while walking within the confines of the rails by sequentially gripping and releasing one or both rails while walking. The resulting upper extremity movement is largely in the sagittal plane as opposed to including some movement in the transverse plane as occurs when arm swinging occurs naturally and more shoulder rotation occurs. If one is able to turn at the end of the walkway, one can move hands from one rail to the other, and thence continue walking in a face forward direction in the reverse or opposite direction. A wheelchair is sometimes pushed behind a patient within the bars, for safety purposes. Parallel bars can also be used as a stable environment for initial gait training with one or two canes or crutches, as one can grab one or both rails as needed if one needs additional support.
Currently, a device which provides unilateral forearm platform support—mobile or stationary—for use in railed environments is not available. Hence, in cases in which forearm platform support is needed as well as the stability afforded by parallel bars, the technique used is as follows: a walker (pick up or wheeled) with a platform attachment is placed within the confines of the parallel bars. Hence, two assistive devices instead of preferably one, is being used to perform the training. The resultant technique is potentially unsafe, inefficient, cumbersome, and not as therapeutically effective. The rail is gripped with one hand while the involved upper extremity is placed on the forearm platform, or the uninvolved hand grips the walker grip, and the parallel bar can be grabbed if needed for safety. As the patient walks, the patient sequentially grips the rail on one side, and the walker is advanced as the patient takes steps. As such, the upper extremities are able to move minimally independently of each other (unlike when the patient progresses to platformed walker use outside of the parallel bars and both UEs move simultaneously as they are affixed to the walker grip platform), yet the involved UE is largely immobilized which may be desirable in cases of orthopedic injury but which is not desirable in terms of neurologic rehab. Later, when the patient walks outside of the parallel bars using a platformed walker, it can be confusing to some patients to grip the walker grip as opposed to the rail, while the other arm rests on the platform. A mechanism to practice the same technique which will eventually be used with a platformed walker would be desirable, as well as a mechanism which enables rehabilitation of the UE and gait training in ways which cannot be accomplished with a walker. For those needing bilateral platform support, a bilaterally-platformed walker can also be placed within the confines of parallel bars, for added security of availability of rail(s) to grab if needed.
Other techniques for unilateral UE support include physical assist by a clinician, supporting the UE in a sling, walking with insufficient UE support and/or asymmetric gait and posture, placing a crutch in cases such as UE amputation when residual limb strength is adequate, or using hemiplegic bars which necessitate only unilateral UE function yet thereby does not offer the therapeutic advantages of bilateral UE support needed by many recovering from neurologic injury. Use of a walker with platform attachment(s) may be the only safe/effective option, thereby precluding use of the parallel bars. With neurological rehabilitation techniques incorporating body weight support technologies, if the patient can not actively engage in free reciprocating movement of the arms and/or use one or both upper extremities for support purposes, a. the involved UE(s) are either strapped statically to rails as in the case of treadmill use, or left to dependently hang; b. overground training is done exclusively outside of the parallel bars which otherwise offer therapeutically-enhancing functionality to the rehab program. Bilateral forearm support can be accomplished with Midland parallel bar glider, yet this device promotes poor posture, is unsafe without braking/resistance components, and is functional unidirectionally.
A patient necessarily releases support of one rail at a time in order to advance and, as such, parallel bars do not offer the continuous support to the patient that walkers afford. This alternating temporary release of UE support can be problematic when significant upper body support is required in order to take steps as in the case of significant weakness and difficulty walking as with incomplete spinal cord injuries, which includes cases truly requiring forearm support for adequate bodily support as well as other cases which are in need for forearm support when gripping function is nonexistent or unsafe. A method to provide continuous support when needed would be desirable. Upper extremity force measurement capabilities would also be desirable and the devices proposed herein could accommodate such upon further development. In cases in which parallel bars (and treadmills) are utilized to work on the components of normal gait, arm swinging cannot be mechanically facilitated or measured in any way, and symmetry of upper extremity excursion distance and velocity cannot be effectively addressed. Symmetry in terms of arm swing magnitude and velocity is preferable during gait training as is the capability to work on coordination between upper extremities and lower extremities. Conversely, independent movement of the UEs, if appropriate and if achieved, in parallel bars, is lost upon progression to use of a walker, unfortunately. Hence, devices to work on such in railed environments are very much needed. It must be noted that rehabilitation goals may not include enabling or increasing back and forth movement of the UE while the forearm support is in use for several different reasons. In these cases, the UE may remain largely fixed in position relative to the body, while the person walks on these devices. Also, while working on these devices, a stationary, stable support is sometimes desirable as is mobile support bilaterally to use while walking or standing in place as a way to do work on arm swinging motions, and on the associated trunk rotation. In parallel bars, if a patient can grip the rail yet has difficulty advancing the UE, there currently is not an apparatus available to mechanically facilitate movement.
A significant issue related to rehabilitative efforts is that higher intensities of aerobic exercise are needed. This could be accomplished in railed devices such as parallel bars and on treadmills by offering a method to enable mobile grip or mobile forearm platform support. Upper extremity movement adds to the aerobic stimulus. Greater intensities could also be achieved by the addition of bodily and postural support offered by forearm platforms.
Mobility aids are needed by amputees who have both an UE and a lower extremity (LE) amputation for initial training in parallel bars, both in terms of provision of a means of UE support for the lower extremity(ies), as well as for early weight bearing through, and functional use of, the involved UE during the functional task of walking. Below elbow amputees need a forearm platform support or a method to connect the residual limb to an alternate support surface. Above elbow amputees need a mechanism to enable support via a forearm support surface. Adequate weight-bearing support for early ambulation is needed, as well as UE functional training which could both neurologically facilitate LE recovery as well as result in increased likelihood of long term UE prosthesis use.
Generalized upper body weakness in those with lower extremity pathology/dysfunction often presents a fall hazard during gait training with walkers and in these cases, forearm platforms are used. An obvious need for unilateral or bilateral forearm platform support in parallel bars exists for this same reason, particularly as parallel bars are used when greater difficulty with walking exists.
One type of parallel bar unit is called “hemiplegic bars” designed for those patients such as those afflicted with hemiplegia who are able to grip and support their body weight while walking with only one UE. As opposed to two parallel bars which are not attached at the ends, this unit has a continuous, oblong-shaped railing. A patient can walk continuously around the device by hanging onto the railing with the stronger/unaffected upper extremity. The resultant gait pattern is similar to that used with a hemiwalker. The weak upper limb is not therapeutically stimulated during gait training with this assistive device unless manually, laboriously assisted by additional rehabilitation personnel. Therapists' access to a patient is enhanced with hemiplegic bars as compared to standard parallel bars. Another mechanism to therapeutically stimulate the UE during functional weight bearing activities is needed.
Locomotor training refers to the rehabilitative approach used for persons with neurologic dysfunction, and includes gait training on a treadmill (with rails available), in parallel bars, and overground with or without an assistive device with body weight support, as well as eventually overground with the least restrictive assistive device. During locomotor training, the patient grabs the device railings in a stationary manner, or variably, the arms hang freely and rhythmic arm movement occurs to the extent the individual is able to perform such arm movement independently or with verbal cuing. Sometimes the patient grabs pole(s) and while holding parallel to the ground, movement of the arms can be facilitated by the therapist. Often used during locomotor training are expensive body weight support systems which provide sling suspension for over ground, treadmill, or parallel bar gait training as a way to facilitate ambulation. Expensive robotic exoskeletons also exist for support and movement of the lower limbs. Specific UE robotic training to date typically involves arm movements occurring during tasks other than the functional task of ambulating. An inexpensive form of functional UE robotics is proposed herein as the reciprocating and reverse motion linkages could be mechanized. There currently are not alternate support surfaces for the upper extremit(ies) on these devices, nor is there a mechanism to facilitate arm movement as would be desirable as an important component of locomotor training. Locomotor training principles include providing for maximal sustainable loads on the lower extremities, maintaining erect head and neck and trunk posture, avoiding weight bearing on the arms and facilitating reciprocal arm swing, among others. High volumes of receptive movements of the arms and legs in functionally-meaningful movement patterns is desirable. As such, in cases of locomotor training when one may have tendency to excessively weight bear through the arms when gripping the rail, platform support may be beneficial in this respect as it is thought that when attempting to minimize UE weight-bearing, it may be easier to do so when forearm support instead of rail gripping is done. Gripping (nonweight-bearing) has been found to be neurologically-enhancing, so incorporation thereof is desirable, and a grip handle is indeed available on a forearm platform assembly which will be beneficial in this regard. A way to continue this repetitive movement therapy in a home setting following therapy would be desirable. Many treadmills already exist in facilities and homes, in need of attachable devices to enhance usage, safety, and functionality, particularly by neurologic patients in order to continue training in the home which was initiated in the clinic. Resting the UEs on supports which enable repetitive reciprocating arm movements, and hence continuing to perform training in railed environments which enable a mechanical means to do so, may be beneficial as opposed to allowing the UEs to hang freely during neurologic rehab, among other types of rehab. Whereas in current neurologic rehabilitation the emphasis is on avoiding weight-bearing through the upper extremities, including training in stepping and ambulation activities, utilizing forearm platform support and instructing in incremental UE weight-bearing using such could facilitate continuation of rehabilitation efforts outside of the clinic with railed devices, such as in the home, for cases in which this could be done safely. The same technique(s) could be continued with a novel walker which provides for similar functionality.
Treadmills are often used for gait training and for exercise training purposes in rehabilitation and other medical, sports, and fitness settings. Many different designs exist, with variable rail location, rail diameter, rail length, etc. Indeed, some treadmill railings, unlike parallel bar railings, do not have a circular cross-section but instead may be one of a variety of different shapes. If upper body support is needed while walking/running on a treadmill, one must hang on to the railing. There currently does not exist a device which enables mobile UE support on a treadmill when one is able to grip the rail such as would be therapeutic for some neurologic patients as well as for healthy individuals requiring support yet wishing to move the arms while using a treadmill. Rail support is available on the front and often along the sides of the treadmill. The upper body is stationary and effectively immobilized when one hangs onto rails and the upper extremities are fixed anteriorly or at one's sides, and disadvantageous excessive weight bearing through the UEs can result. There is currently no apparatus available to provide mobile or stationary unilateral or bilateral forearm support on treadmills when one requires this type of support for reasons noted above. If an individual is able to walk, jog, or run on a treadmill without hanging onto a rail, either independently or as a result of being mechanically supported such as by a sling support mechanism, or robotics exoskeleton, a mechanical device to facilitate upper extremity movement for strengthening or other neurological or functional reasons does not exist. Typically, if one has unilateral UE involvement such that one can support oneself with only one UE, yet remains able to ambulate on a treadmill, the involved UE remains unsupported, unstimulated, and nonfunctional, and unable to provide necessary stimulus for more symmetrical gait. Alternately, with unilateral or bilateral UE involvement, a therapist may support or mobilize the involved UE, although if the LE requires assistance, this is typically provided preferentially. Otherwise, the UE is allowed to hang freely thus not receiving any type of therapeutic intervention.
There exist bariatric treadmills (and parallel bars) which have greater load limits and which have railings on both sides. More severely-involved bariatric patients, however, are unable or unsafe to utilize these devices, due to inability to bear sufficient weight through one's arms via gripping the rail. Forearm platform supports for use in these railed environments are hence needed, as they are likewise needed and often incorporated in various walking frames and walkers.
Hence, in railed environments such as parallel bars and treadmills, a rigid framed walker, or other mechanisms/devices to accommodate an upper extremity with various types of mobile (and stationary) support surfaces do not exist, nor do devices exist to enable, facilitate, and potentiate arm movement in these environments or to achieve additional trunk rotation and movement of the upper extremities in a combination of planes of movement such as occurs during normal arm swing/gait, as a product extension proposed herein will provide.
In terms of acute medical care, a safe, efficient, readily-accessible, inexpensive low tech method of initiating functionally relevant and neurologically-stimulating movement therapy at bedside would be desirable. Nothing currently exists for this purpose. The devices proposed herein could be used for this purpose as well.
Regarding related art, there are forearm platform attachments for walkers and rollators, and at least one of these enables adjustment of the forearm support in a sagittal plane. These units cannot be used for parallel bar or treadmill application as they are designed to attach specifically to one or more varieties of walker frames. Indeed, there are also some walkers and rollators with platforms integrated into the frame. Stationary forearm support(s) are manufactured by a foreign company, specifically compatible with some of their treadmills. There are not any devices which offer mobile upper extremity support which can be variably attached to treadmill railings when platform or any other type of support is desired.
For parallel bar application, there exists the following device. A Midland Parallel Bar Glider is an expensive device comprised of two platform supports necessarily interconnected and which move as one piece in one direction along the rails. WO1996002208A2 appears related to the Midland device and discloses a one-piece frame which is placed on top of both rails, and which has bilaterally-placed forearm supports. Both devices are movably positioned on, and attached to, both rails of the parallel bar unit and support is necessarily unremovable bilateral forearm platform support. The devices cannot be used to unilaterally support an UE, alternate types of support cannot be incorporated, and independent movement of the UEs cannot occur. A strong limb cannot potentiate movement in a weaker limb. One or both of the devices specify inclusion of a braking mechanism. The primary purpose of these technologies seems to be provision of support when significant bodily support is needed to enable ambulation in parallel bars. Significant limitations of these devices exist including, both forearms must be placed on platforms and supported, this device encourages poor posture similar to the way that a platformed walker encourages poor posture, the entire upper extremity is immobilized, and the units are extremely expensive and cumbersome to attach to the parallel bars. They are not meant for use on other railed devices such as treadmills or hemiplegic bars. The upper extremities cannot move independently as is needed to achieve a reciprocating gait pattern, or to facilitate balance reactions, or to work on components of gait as related to arm swing and trunk rotation. The upper extremities are necessarily kept in a position anterior to the frontal plane of the body, i.e. with shoulders slightly flexed, which is not a neutral posturing. Neural coupling—necessary for neural recovery of LEs for ambulation—is prohibited: the upper extremities cannot move in a reciprocating manner. Product extensions and therapeutically-stimulating linkages proposed herein cannot be incorporated with these devices. Furthermore, with the Midland device, when a patient reaches one end of the parallel bars, the patient must be assisted to sit down, and wheeled backwards to the starting point in a wheelchair, hence necessitating greater personnel assist and resulting in treatment inefficiencies. Practicing turns, walking back in the opposite direction, and continuous ambulation resulting in greater distances walked is not possible with this device. Also, sidestepping cannot be accomplished with either device.
In terms of technology which enables UE movement concurrent with LE movement, ergometers exist. One model of treadmill has mobile levers which one can hang onto and which move in a back-and-forth manner, typically for purposes of adding upper body resistance exercise, yet the movement does not mimic that of arm swing and significant UE function bilaterally is needed to hang onto the levers and use a device such as this. Also, it can only be used via gripping the handles with outstretched arms. Other ergometers (exercise machines) exist which offer bilateral arm movement while in a seated (as opposed to standing) position, such as a Nu-Step. Technology is needed which can be incorporated into use with the plethora of treadmills already present in clinics, facilities, and homes, for purposes noted above.
A need exists for an improved arrangement that provides at least one or more of the following features, as well as still other features and benefits